Pittsburgh-based UPMC must continue to provide in-network services to members of Highmark's Medicare Advantage plans, the Pennsylvania Supreme Court ruled Monday.
The ruling affirms a state judge's decision in May which said the system must remain an in-network provider for Highmark's Medicare Advantage plans through the term of a consent decree reached between the two battling organizations and state officials last year. The state took UPMC to court after the system announced plans to end its Advantage contracts with Highmark because Highmark allegedly failed to pay UPMC contracted rates for cancer care.
“The Supreme Court, in a split decision, recognized the basic ambiguity of the Consent Decrees and that contracts for Medicare Advantage will remain in place,” UPMC spokesman Paul Wood said in a statement Monday. “UPMC will, of course, comply with the decision.”
Pennsylvania Gov. Tom Wolf said in a statement Monday he was pleased with the decision, calling it a “victory for seniors across Western Pennsylvania.”
“I have also made very clear that the decision to cancel Medicare Advantage for over 180,000 seniors was wrong, and I vowed to fight that decision by any means necessary, including through legal action,” Wolf said.
Attempts to reach Highmark for comment were not immediately successful Monday evening.
The decision comes about a week before the end of Medicare Advantage open enrollment.
As part of its case, UPMC had alleged that Highmark stopped paying UPMC contracted rates for cancer care and owed the system $143 million. The consent decree, UPMC argued, allowed it to end its contracts under such circumstances.
The judges, however, on Monday cited a clause within that consent agreement that says “with respect to Highmark's covered vulnerable populations, UPMC shall continue to contract with Highmark at in-network rates for all of its hospital, physician and appropriate continuity of care services for CHIP, Highmark Signature 65, Madigan and commercial retiree carve out as long as Highmark does not make unilateral material changes to these programs.”
“After careful review, we affirm the order of the Commonwealth Court finding that the vulnerable populations clause of the consent decree requires UPMC to 'be in a contract' with Highmark for the duration of the consent decree,” Justice Debra McCloskey Todd wrote in the opinion.
Highmark and UPMC have been feuding since Highmark, the largest health insurer in the region, acquired a rival health system—now called Allegheny Health Network—in 2013. A contract between them expired at the end of last year, and a transition plan approved by the Pennsylvania Insurance Department outlined which UPMC facilities and services would be in-network and out-of-network after the contract's expiration. That followed a consent decree signed in June outlining similar measures.
UPMC and Highmark also reached a separate agreement earlier this month on the terms for continuing care for Highmark patients currently being treated at UPMC facilities.
In a recent interview with Modern Healthcare, Highmark CEO David Holmberg described the dynamic between the rival systems as a result of UPMC "wanting to go their own way."
"We think the future of healthcare may get decided in Pittsburgh," Holmberg added, because the friction between the rival systems "is creating real innovation and new care models that have the potential for really making a difference on a national level."
